Chapter 20: Nursing Management: Postoperative Care

The postoperative period begins immediately after surgery and continues until the patient is
discharged from medical care.

POSTANESTHESIA CARE UNIT

 Priority care in the postanesthesia care unit (PACU) includes monitoring and
management of respiratory and circulatory function, pain, temperature, and the
surgical site.

 Assessment begins with an evaluation of the airway, breathing, and circulation

(ABC). Any evidence of respiratory compromise requires prompt intervention.

 Pulse oximetry monitoring is initiated because it provides a noninvasive

means of assessing the adequacy of oxygenation.

 Electrocardiographic (ECG) monitoring is initiated to determine cardiac rate and

rhythm.

 The initial neurologic assessment focuses on level of consciousness, orientation,

sensory and motor status, and size, equality, and reactivity of the pupils.

 Because hearing is the first sense to return, the nurse explains all activities to the
patient from the moment of admission to the PACU.

POTENTIAL COMPLICATIONS IN THE PACU

Respiratory
 In the immediate postanesthesia period, the most common causes of airway
compromise include airway obstruction, hypoxemia, and hypoventilation.

 Patients at risk include those who have had general anesthesia, are older, smoke
heavily, have lung disease, are obese, or have undergone airway, thoracic, or
abdominal surgery.

 Hypoxemia, specifically an arterial oxygen tension (PaO2) of less than 60 mm

Hg, is characterized by a variety of nonspecific clinical signs and symptoms,
ranging from agitation to somnolence, hypertension to hypotension, and
tachycardia to bradycardia.
o The most common cause of postoperative hypoxemia is atelectasis,
which occurs as a result of retained secretions or decreased respiratory
excursion.
o Other causes include pulmonary edema, aspiration, and bronchospasm.

 Hypoventilation is characterized by a decreased respiratory rate or effort,

hypoxemia, and an increasing arterial carbon dioxide tension (PaCO2), which also
 known as hypercapnia.

 The nurse evaluates airway patency; chest symmetry; and the depth, rate, and
character of respirations. The chest wall is observed for symmetry of movement with
a hand placed lightly over the xiphoid process. Breath sounds are auscultated
anteriorly, laterally, and posteriorly.

 Regular monitoring of vital signs and use of pulse oximetry are necessary for
early recognition of respiratory problems.
 The presence of hypoxemia from any cause may be reflected by rapid breathing,
gasping, apprehension, restlessness, and a rapid or thready pulse.

 Proper positioning facilitates respiration and protects the airway. Unless

contraindicated by the surgical procedure, the unconscious patient is positioned in a
lateral “recovery” position. Oxygen therapy will be used if the patient has had
general anesthesia and/or the anesthesia care provider (ACP) orders it.

Cardiovascular
 The most common cardiovascular problems include hypotension, hypertension, and
dysrhythmias. Patients at greatest risk include those with alterations in respiratory
function, a history of cardiovascular disease, the elderly, the debilitated, and the
critically ill.

 Hypotension is most commonly caused by unreplaced fluid and blood loss, which
may lead to hypovolemic shock. Treatment of hypotension begins with oxygen
therapy to promote oxygenation of hypoperfused organs.

 Hypertension is most frequently the result of pain, anxiety, bladder

distention, or respiratory compromise. Treatment of hypertension will center
on eliminating the precipitating cause.

 Dysrhythmias are often the result of hypokalemia, hypoxemia, hypercarbia,

alterations in acid-base status, circulatory instability, hypothermia, pain, surgical
stress, and preexisting heart disease. Treatment is directed toward eliminating the
cause.

 Vital signs are monitored frequently (i.e., every 15 minutes, or more often until
stabilized, and then at less-frequent intervals).

 The anesthesia care provider (ACP) or surgeon should be notified if the following occur:
o Systolic BP is less than 90 mm Hg or greater than 160 mm Hg.
o Pulse rate is less than 60 beats per minute or more than 120 beats per minute.
o Pulse pressure (difference between systolic and diastolic pressures) narrows.
o BP gradually decreases during several consecutive readings.
o There is a change in cardiac rhythm.
 o There is a significant variation from preoperative readings.

Neurologic
 Emergence delirium, or “waking up wild,” can include restlessness, agitation,
disorientation, thrashing, and shouting. It may be caused by anesthetic agents,
hypoxia, bladder distention, pain, electrolyte abnormalities, or the patient’s state of
anxiety preoperatively.

 Delayed emergence is most commonly caused by prolonged drug action,

particularly of opioids, sedatives, and inhalational anesthetics, as opposed to
neurologic injury.

 The most common cause of postoperative agitation is hypoxemia.

 Until the patient is awake and able to communicate effectively, it is the

responsibility of the PACU nurse to act as a patient advocate and to maintain the
patient’s safety.

 The patient’s level of consciousness, orientation, and memory and ability to

follow commands are assessed. The size, reactivity, and equality of the pupils are
determined.

 Pain is a common problem and a significant fear for the patient in the PACU.

Body Temperature
 Hypothermia, a core temperature less than 96.8º F (36º C), occurs when heat
loss is greater than heat production. Heat loss during the perioperative period
can be due to radiation, convection, conduction, and evaporation, infusion of
cool IV fluids, and ventilation with dry gases.
 Frequent assessment of the patient’s temperature is important to detect
patterns of hypothermia and/or fever.

POTENTIAL PROBLEMS IN THE CLINICAL UNIT

Respiratory
 Common causes of respiratory problems are atelectasis and pneumonia,
especially after abdominal and thoracic surgery.

 Deep breathing is encouraged to facilitate gas exchange. The patient

should be encouraged to breathe deeply 10 times every hour while awake.

 The patient’s position should be changed every 1 to 2 hours to allow full chest
expansion and to increase perfusion of both lungs. Ambulation, not just sitting
in a chair, should be aggressively carried out as soon as physician approval is
given.
Cardiovascular
 Postoperative fluid and electrolyte imbalances are contributing factors to
cardiovascular problems. Fluid overload may occur when IV fluids are
administered too rapidly, when chronic (e.g., cardiac, renal) disease exists, or when
the patient is an older adult.

 Syncope (fainting) may occur as a result of decreased cardiac output, fluid

deficits, or defects in cerebral perfusion.

 An accurate intake and output record should be kept, and laboratory findings
(e.g., electrolytes, hematocrit) should be monitored.

 The nurse should be alert for symptoms of too slow or too rapid a rate of
fluid replacement.
 Hypokalemia causing dysrhythmias can be a consequence of urinary and
gastrointestinal (GI) tract losses, and inadequate potassium replacement.

 Deep vein thrombosis (DVT) may form in leg veins as a result of inactivity,
body position, and pressure, all of which lead to venous stasis and decreased
perfusion.
o Leg exercises should be encouraged 10 to 12 times every 1 to 2 hours while
awake. Early ambulation is the most significant general nursing
measure to prevent postoperative complications.
o Subcutaneous heparin (or low-molecular-weight heparin
[LMWH]) in combination with antiembolism stockings are used
to prevent DVT.

Neurologic
 Two types of postoperative cognitive impairment are seen in surgical patients:
delirium and postoperative cognitive dysfunction.

 Confusion or delirium may arise from a variety of psychologic and physiologic

sources, including fluid and electrolyte imbalances, hypoxemia, drug effects, sleep
deprivation, and sensory deprivation or overload.

 Alcohol withdrawal delirium is a reaction characterized by restlessness, insomnia

and nightmares, irritability, and auditory or visual hallucinations.

 To prevent or manage postoperative delirium, the nurse should address factors

known to contribute to the condition.

 The nurse should attempt to prevent psychologic problems in the postoperative

period by providing adequate support for the patient.

 Pain is a common problem during the postoperative period. Pain can contribute to
 dysfunction of the immune system and blood clotting, delayed return of normal
gastric and bowel function, and increased risk of atelectasis and impaired
respiratory function.

 The patient’s self-report is the single most reliable indicator of pain.

 Identifying the location of the pain is important. Incisional pain is to be expected,

but other causes of pain, such as a full bladder, may be present.

 The most effective interventions for postoperative pain management include

using a variety of analgesics.

 Postoperative pain relief is a nursing responsibility. The nurse should notify the
physician and request a change in the order if the analgesic either fails to relieve the
pain or makes the patient excessively lethargic or somnolent.

 Patient-controlled analgesia (PCA) and epidural analgesia are two alternative

approaches for pain control.

Body Temperature and Infection

 Temperature variation provides valuable information about the patient’s status.
Fever may occur at any time. A mild elevation (up to 100.4º F [38º C]) during the
first 48 hours usually reflects the surgical stress response.

 Wound infection, particularly from aerobic organisms, is often accompanied by a

fever that spikes in the afternoon or evening and returns to near-normal levels in the
morning.

 Intermittent high fever accompanied by shaking chills and diaphoresis

suggests septicemia.

Gastrointestinal
 Numerous factors have been identified as contributing to the development of nausea
and vomiting, including gender (female), history of motion sickness or previous
postoperative nausea and vomiting, anesthetics or opioids, and duration and type of
surgery.
o If vomiting occurs, it is important to determine the quantity,
characteristics, and color of the vomitus.
o The abdomen is assessed for distention and the presence of bowel
sounds. All four quadrants are auscultated to determine the presence,
frequency, and characteristics of the sounds.
o Postoperative nausea and vomiting are treated with the use of
antiemetic or prokinetic drugs.
o Abdominal distention is caused by decreased peristalsis as a result of
handling of the intestine during surgery and limited dietary intake before
 and after surgery.
o Abdominal distention may be prevented or minimized by early and
frequent ambulation.

 A nasogastric tube may be used to decompress the stomach to prevent

nausea, vomiting, and abdominal distention.

Urinary
 Low urine output (800 to 1500 ml) in the first 24 hours after surgery may be
expected, regardless of fluid intake.

 Acute urinary retention can occur in the postoperative period due to anesthesia,
location of the surgery (e.g., lower abdominal, pelvic), pain, immobility, and the
recumbent position in bed.
o The urine of the postoperative patient should be examined for both quantity
and quality.
o Most patients urinate within 6 to 8 hours after surgery. If no voiding
occurs, the abdominal contour should be inspected and the bladder assessed
for distention.
Wound Infection
 Wound infection may result from contamination of the wound from three major
sources: exogenous flora present in the environment and on the skin, oral flora, and
intestinal flora.

 The incidence of wound sepsis is higher in patients who are malnourished,

immunosuppressed, or older, or who have had a prolonged hospital stay or a
lengthy surgical procedure (lasting more than 3 hours).

 Evidence of wound infection usually does not become apparent before the third
to the fifth postoperative day.
o Local manifestations include redness, swelling, and increasing pain and tenderness
at
the site.
o Systemic manifestations are fever and leukocytosis.

 Nursing assessment of the wound and dressing requires knowledge of the type of
wound, the drains inserted, and expected drainage related to the specific type of surgery.
o A small amount of serous drainage is common from any type of wound.
o If a drain is in place, a moderate to large amount of drainage may be expected.
o Drainage is expected to change from sanguineous (red) to serosanguineous
(pink) to serous (clear yellow). The drainage output should decrease over hours
or days, depending on the type of surgery.
o Wound infection may be accompanied by purulent drainage. Wound
dehiscence (separation and disruption of previously joined wound edges) may
be preceded by a sudden discharge of brown, pink, or clear drainage.
 o When drainage occurs on the dressing, the type, amount, color, consistency, and
odor of drainage are noted.

DISCHARGE
 The choice of discharge site is based on patient acuity, access to follow-up care,
and the potential for postoperative complications.

 The decision to discharge the patient from the PACU is based on written
discharge criteria.

 Discharge to the clinical unit:

o Vital signs should be obtained, and patient status should be compared with
the report provided by the PACU. Documentation of the transfer is then
completed, followed by a more in-depth assessment. Postoperative orders
and appropriate nursing care are then initiated.

 Ambulatory surgery discharge:

o The patient leaving an ambulatory surgery setting must be mobile and
alert to provide a degree of self-care when discharged to home.
o The nurse specifically documents the discharge instructions provided to the
patient and family.

GERONTOLOGIC CONSIDERATIONS
 Older adults have decreased respiratory function, including decreased ability to
cough, decreased thoracic compliance, and decreased lung tissue, placing them at
greater risk during the perioperative period.

 Drug toxicity is a potential problem. Renal and liver function must be carefully
assessed in the postoperative phase to prevent drug overdosage and toxicity.